Migraines and stroke, guidance for transcatheter aortic valve replacement, and more

In the News is a product of ACP Hospitalist Weekly, an e-newsletter provided every Wednesday by ACP Hospitalist.

Migraine may be linked to perioperative stroke, hospital readmission

History of migraine, especially migraine with aura, may be associated with increased
stroke risk and risk for hospital readmission after surgery, according to a recent
study.

Researchers performed a prospective hospital registry study at Massachusetts General
Hospital in Boston and two satellite campuses from January 2007 to August 2014 to
determine whether risk for perioperative ischemic stroke and subsequent increased
hospital readmission rates are associated with migraine in surgical patients. The
study's primary outcome was perioperative ischemic stroke within 30 days after surgery.
Hospital readmission within 30 days of surgery was the secondary outcome, and postdischarge
stroke and neuroanatomical stroke location were exploratory outcomes. The study results
were published online by BMJ on Jan. 10.

A total of 124,558 patients who had surgery under general anesthesia and with mechanical
ventilation were included in the study. Slightly over half (54.6%) were women, and
the mean age was 52.6 years. Of these, 10,179 (8.2%) had any type of migraine diagnosis,
1,278 (12.6%) with aura and 8,901 (87.4%) without. Perioperative ischemic stroke occurred
within 30 days of surgery in 771 patients (0.6%), with increased risk seen in patients
with migraine versus those without (adjusted odds ratio, 1.75; 95% CI, 1.39 to 2.21).
Migraine with aura was associated with higher risk compared to migraine without aura
(adjusted odds ratio, 2.61 [95% CI, 1.59 to 4.29] versus 1.62 [95% CI, 1.26 to 2.09],
respectively).

The researchers calculated a predicted absolute risk of 2.4 perioperative ischemic
strokes for every 1,000 surgical patients and found that this risk was 4.3 for every
1,000 patients with migraine, 3.9 for every 1,000 patients with migraine but no aura,
and 6.3 for every 1,000 patients with migraine and aura. Rate of readmission within
30 days of discharge was also higher in patients with migraine (adjusted odds ratio,
1.31; 95% CI, 1.22 to 1.41).

The authors noted that they based their classification of migraine and migraine with
aura on ICD-9 codes in the hospitals' data registry and that some patients may have
been misclassified. In addition, they pointed out that use of the available ICD-9
codes could have led to inclusion of patients who had the most severe symptoms of
aura, possibly a subgroup at higher risk for stroke. However, they concluded that
their results indicate that migraine, especially migraine with aura, should be included
as a marker for increased ischemic stroke risk, including perioperatively.

They suggested that use of high-dose vasopressors during surgery and history of a
possible right-to-left shunt might be modifiable risk factors in patients who have
migraine with aura and said that close postoperative monitoring for early detection
of stroke symptoms in high-risk patients is essential. Migraine should be included
in assessment of perioperative risk in patients preparing for surgery, the authors
suggested.

Guidance issued for decision making on transcatheter aortic valve replacement

The American College of Cardiology recently released an expert decision consensus
pathway to help guide decision making about transcatheter aortic valve replacement
(TAVR) in patients with aortic stenosis.

The pathway is based on expert consensus and provides point-of-care checklists and
algorithms about TAVR in four sections: preprocedure evaluation, imaging modalities
and measurements, key issues in performing the procedure, and recommendations for
patient follow-up.

The decision pathway stressed the need for shared decision making and patient education
when determining whether TAVR should be performed and recommended that initial assessment
include evaluation of symptoms of aortic stenosis, disease severity, and standard
clinical data, in addition to major cardiovascular and noncardiovascular comorbid
conditions. The clinical team should also review echocardiographic measures of aortic
stenosis severity, confirm disease severity, and perform additional imaging as needed,
the pathway said. Frailty and disability should also be considered, along with cognitive
function and futility.

An included checklist for post-TAVR clinical management outlined the key steps to
be taken immediately after the procedure, including waking from sedation, postprocedure
monitoring, pain management, early mobilization, and discharge planning.

Patients should be extubated early and their mental status should be monitored, the
checklist said. Telemetry and vital signs should be monitored according to hospital
protocol, intake and output should be monitored, and routine labs should be done.
The access site should also be monitored for bleeding, hematoma, or pseudoaneurysm,
the checklist said.

When planning discharge, clinicians should resume the patient's preoperative medications,
plan the discharge location, order an echocardiogram and electrocardiogram before
discharge, and schedule postdischarge clinic visits, according to the checklist.

The full decision pathway was published Jan. 4 by the American College of Cardiology.

New pathway may rule out more patients, miss fewer MIs than guideline-approved pathway

An early rule-out pathway for myocardial infarction (MI) may rule out more patients
on presentation and miss fewer index or recurrent MI cases than the rule-out pathway
recommended by the European Society of Cardiology (ESC), according to a recent study.

Researchers compared the safety and efficacy of the ESC rule-out pathway (based exclusively
on high-sensitivity cardiac troponin concentrations <99th percentile at presentation
[16 ng/L for women and 34 ng/L for men], or at three hours if symptoms last less than
six hours) and the new pathway, which incorporates lower cardiac troponin concentrations
(risk-stratification threshold of 5 ng/L at presentation, with retesting at three
hours if symptom onset is less than two hours from presentation or if ≥5 ng/L
at presentation).

Patients with suspected acute coronary syndrome were recruited from the ED of a tertiary
care hospital in Scotland into a sub-study of the High-Sensitivity Troponin in the
Evaluation of patients with Acute Coronary Syndrome (High-STEACS) trial, where the
pathway was developed. They evaluated the negative predictive value (NPV) of each
pathway using a composite endpoint of index type 1 MI, or subsequent type 1 MI or
cardiac death at 30 days.

Results were published online on Dec. 29, 2016, by Circulation and appear in the March 7 print issue.

The ESC pathway ruled out 342 patients (28.1%) at presentation and 961 patients (78.9%)
by three hours. This approach missed 18 index type 1 MIs (four on presentation, 14
at three hours) and two subsequent MIs within 30 days (overall NPV, 97.9%; 95% CI,
96.9% to 98.7%). The sensitivity of this pathway was 89.3% (95% CI, 84.9% to 93.5%).

In comparison, the High-STEACS pathway ruled out 496 patients (40.7%) at presentation
and 904 patients (74.2%) by three hours. This approach missed two index type 1 MIs
at three hours and two subsequent MIs at 30 days (all events were also missed by the
ESC pathway), for an overall NPV of 99.5% (95% CI, 99.0% to 99.9%). The sensitivity
of this pathway was 97.7% (95% CI, 95.5% to 99.5%).

Limitations of the study include its observational design and the fact that true efficacy
and safety of the High-STEACS pathway are unknown because no patients were discharged
on the basis of pathway decisions, the study authors noted. Utilizing low cardiac
troponin concentrations to risk-stratify patients “identifies more patients
as low risk at presentation, and has a better overall negative predictive value than
guideline approved pathways based solely on the 99th centile,” they wrote.
“Implementation of this pathway has the potential to improve the efficiency
and safety of early rule-out approaches for patients with suspected acute coronary
syndrome.”

Study looks at frequency of ‘surprise’ medical bills

Twenty percent of inpatient admissions from the ED, 14% of outpatient visits to the
ED, and 9% of elective inpatient admissions were linked to “surprise”
medical bills in a recent study.

The study defined a surprise medical bill as “a bill from an out-of-network
provider that was not expected by the patient or that came from an out-of-network
provider not chosen by the patient.” Researchers used data from a nationwide
claims database that tracks patients with employer-sponsored health insurance to measure
the rate of such bills among those whose health plans offered incentives for using
in-network clinicians. Data from 2007-2014 were considered.

Photo by Thinkstock

Emergency cases were considered likely to lead to a surprise medical bill if they
involved emergency care at an in-network hospital where the ED or other hospital physicians
were out of network, if they involved an admission by an in-network ED at an in-network
hospital but treatment by an out-of-network physician, and if they involved transportation
by ambulance to an out-of-network hospital for emergency care. Elective inpatient
admissions were considered likely to lead to a surprise medical bill if they involved
an in-network hospital and primary care physician (or no primary care physician was
identified in the database) but at least one other clinician or service that was out
of network. The study results were published online in December 2016 by Health Affairs.

In 2014, the most recent year for which data were available, 20% of inpatient admissions
from the ED, 14% of outpatient visits to the ED, and 9% of elective inpatient admissions
were classified as likely to lead to surprise medical bills. This represented a decrease
in all categories from 2007 (of approximately 28%, 18%, and 14%, respectively). Patients
were more likely to get a surprise medical bill if they were older and if their diagnosis
was medically complex. ED outpatient visits were less likely to result in a surprise
medical bill than ED visits that led to an inpatient admission, which “suggests
that the likelihood of receiving a surprise medical bill increases with the severity
and complexity of a patient treatment episode,” the authors wrote. Likewise,
inpatient admissions were more likely to lead to a surprise medical bill if length
of stay was longer and involved more services and procedures. Physicians who were
not based in the hospital were the most likely source of potential surprise bills.

The study authors noted that they could not determine whether patients expected to
receive medical bills and could only look at conditions in which surprise bills were
likely. However, they concluded that based on their results, patients who receive
bills for out-of-network care are often surprised by them. They speculated that the
decrease in rates of surprise bills over time may be related to increased employment
of physicians by hospital systems or large group practices but said further research
was needed in that area. They also noted that the finding of more surprise medical
bills among patients admitted with more severe diagnoses was “troubling”
because insurance is meant to provide more financial protection in such cases.

“Patients with employer-sponsored insurance can receive treatment from out-of-network
providers in situations where they likely expect their care to be in network or they
are unable to choose an in-network provider, which leads to surprise medical bills
and possibly to unavoidable medical financial burdens,” the authors wrote.
“More research is needed to better understand the factors that contribute to
or could ameliorate this problem.”

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